Long Term Disability Benefits Instructions - Vermonthumanresources.vermont.gov/sites/humanresources/files/documents/LT… · SI 3379 RCO 1 of 13 (7/01) Long Term Disability Benefits

SI 3379 RCO 1 of 13 (7/01)

Long Term Disability BenefitsInstructionsThe Standard Benefit AdministratorsPO Box 5031 White Plains NY 10602-5031 800.426.4332 Tel 800.378.8361 Fax

PLEASE READ CAREFULLY

Your application for benefits consists of four forms. Every space on these forms should be filled in to avoid delay inprocessing your application. If a section does not apply, or information is not available, “NA” should be written in the spaceso that we know you did not overlook that particular question. If a form is received incomplete, it may be returned forcompletion.

The four forms are:

1. The Employee’s Statement

l Answer every question completely. Be sure to use the appropriate section for injury, sickness or pregnancy.If a question does not apply to you write “NA”.

l Use an additional page, if necessary, to give full and complete answers.

l Attach copies of any Social Security, Public Employees Retirement System, Workers’ Compensation orother benefit determinations you have received. If you have applied for any other benefits but have notyet received them, please send a copy of the application receipt. This information is needed to accuratelycalculate your monthly benefits. If you are unable to make copies of these documents please send theoriginals. We will photocopy and return them to you promptly.

l Remember to sign and date your statement. An unsigned or undated statement will be returned to you.

2. The Authorization to Obtain Information

l Please sign and date this form and attach it to the Employee’s Statement. Your signature lets The Standardor its agent, The Standard Benefit Administrators, get the information about you that we need to deter-mine your eligibility for benefits. The authorization also lets The Standard or its agent, The StandardBenefit Administrators, release this information to specific persons. You will receive a copy of this Authori-zation upon your request.

3. The Attending Physician’s Statement

l Part A should be completed by you.

l Part B should be completed by your physician. If you have seen more than one physician for your disability,a statement should be completed by each physician. (You may request additional forms from your employer.)Your physician(s) should mail the completed form directly to The Standard Benefit Administrators.

4. The Employer’s Statement

l This form should be completed by your employer, who will mail it to The Standard Benefit Administrators.

You are responsible for making sure all required forms are completed and returned to our office. If you have any questions,our office is here to help you.

SI 3379 RCO 2 of 13 (7/01)

Long Term Disability BenefitsEmployee’s StatementThe Standard Benefit AdministratorsPO Box 5031 White Plains NY 10602-5031 800.426.4332 Tel 800.378.8361 Fax

Please type or print. Form may be returned for unanswered questions.

1. CLAIMANT

Full Name: Social Security No.:

Address: City: State: Zip Code:

Phone No.: ( ) Patient No.:

Birthdate: Sex: Male Female Height: Weight:

Name of Spouse: Birthdate:

No. of dependent children: Birthdate of youngest:

Did you receive a Certificate of Insurance? Yes No

Brochure? Yes No If no, please contact your employer to obtain a copy.

2. EMPLOYMENT

Name of Employer: Group Policy No.:


Phone No.: ( )

State your job title and describe your duties at work.

Is your disability work-related? Yes No Date of injury:

Have you filed a Workers’ Compensation claim? Yes No If Yes, W.C. claim #

Last full day at work:

Date you became unable to work at your occupation as a result of disability:

Are you now or have you worked at your occupation or any other occupation since the date of your injury? Yes No

If yes, list names of employers, addresses, telephone numbers, and dates of employment.

Are you self-employed at any activity? Yes No

Date you resumed part-time work: Work Phone: ( ) Extension:

Date you resumed full-time work: Work Phone: ( ) Extension:

3. SICKNESS Please list all illnesses which contribute to your being unable to work at your occupation.

Illness: Date First Noticed

Date First Noticed

State what you believe caused your illness.

Describe your symptoms:

Have you ever had the same condition or a related illness before? Yes No Date

SI 3379 RCO 3 of 13 (7/01)


4. INJURY

Describe Injuries:

Cause of Injuries:

Time, Date and Location of Injuries.

5. PREGNANCY

Date you expect to cease work: Expected delivery date:

Actual delivery date: Expected return to work date:

Please indicate any foreseeable complications.

6. ATTENDING PHYSICIAN List all physicians consulted for this injury or illness. Use separate sheet, if needed.

Physician’s Name: Phone No.: ( )

Street Address: Fax No.: ( )

City: State: Zip Code:

Date first consulted for this injury or illness? Date last consulted?









7. HOSPITAL If you were hospitalized for this condition, please complete. Please attach copy of hospital bill if available.

Hospital Name: Address:

From: through: Reason for hospitalization:

From: through: Reason for hospitalization:

8. HISTORY List all illnesses or injuries for which you have received treatment over the past five years. Use separate sheet if needed.Ailment Date Physician’s Name Complete Address

SI 3379 RCO 4 of 13 (7/01)

9. DEDUCTIBLE INCOMEHave you applied for or are you receiving Applied Receiving Date Applied Amount Received Effectivebenefits from: Yes No Yes No For Weekly Monthly Date

a. Social Security

b. Workers’ Compensation

c. State Disability Insurance

d. Retirement or Pension(Employer, PERS, STRS, PERA, etc.)

Please specify type

e. Other(e.g., unemployment or union benefits, etc.)

Please send copies of any letters or notices approving or denying benefits.

10. VOCATIONAL Complete the following and/or attach a resume.

Education level Yes No If no, last grade attended.

Grade School Graduate

High School Graduate

GED

College Graduate Degree Major

Post Graduate Degree Major

Have you attended any trade schools or received other special training? Yes NoIf yes, please describe.

Work Experience: Complete the following starting with your most recent work experience.

Job Title & Employer Dates of Employment Duties Last Salary

1. From:

To:

2. From:

To:

3. From:

To:

4. From:

To:

5. From:

To:

Acknowledgement

I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief.I acknowledge that I have read the applicable fraud notice on the following page of this form.


SIGNATURE DATE

SI 3379 RCO 5 of 13 (7/01)

Long Term Disability BenefitsClaim Form Fraud NoticesThe Standard Benefit AdministratorsPO Box 5031 White Plains NY 10602-5031 800.426.4332 Tel 800.378.8361 Fax

Some states require us to provide the following information to you:

CALIFORNIA RESIDENTS

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a falseor fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADO RESIDENTS

It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for thepurpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance,and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, ormisleading facts or information to the policyholder or claimant for the purpose of defrauding or attempting to defraud thepolicyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to theColorado division of insurance within the department of regulatory agencies.

FLORIDA RESIDENTS

Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or anapplication containing false, incomplete or misleading information is guilty of a felony of the third degree.

NEW JERSEY RESIDENTS

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal andcivil penalties.

PENNSYLVANIA RESIDENTS

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insuranceor statement of claim containing any materially false information or conceals for the purpose of misleading, informationconcerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminaland civil penalties.

ALL OTHER APPLICANTS AND CLAIMANTS

Some states require us to inform you that any person who knowingly and with intent to injure, defraud ordeceive an insurance company, or other person, files a statement containing false or misleading informationconcerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/orcriminal penalties, depending upon the state. Such actions may be deemed a felony and substantial finesmay be imposed.

SI 3379 RCO 6 of 13 (7/01)

Long Term Disability BenefitsAuthorization to Obtain InformationThe Standard Benefit AdministratorsPO Box 5031 White Plains NY 10602-5031 800.426.4332 Tel 800.378.8361 Fax

I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health:

l Any physician, medical practitioner or health care provider.

l Any hospital, clinic, pharmacy or other medical or medically related facility or association.

l Any insurance company.

l Any employer or plan sponsor.

l Any organization or entity administering a benefit program.

l Any educational, vocational or rehabilitational organization or program.

l Any consumer reporting agency, financial institution, accountant, or tax preparer.

l Any government agency (for example, Social Security Administration, Public Retirement System, Railroad RetirementBoard, etc.).

TO GIVE THIS INFORMATION:

l Charts, notes, x-rays, operative reports, lab and medication records and all other medical information aboutme, including medical history, diagnosis, testing and test results. Prognosis and treatment of any physical ormental condition, including:

l Any disorder of the immune system, including HIV, Acquired Immune Deficiency Syndrome (AIDS) orother related syndromes or complexes.

l Any communicable disease or disorder.

l Any psychiatric or psychological condition, including test results.

l Any condition, treatment, or therapy related to substance abuse, including alcohol and drugs.

and:

l Any non-medical information requested about me, including such things as education, employment history, earningsor finances, or eligibility for other benefits (for example, Social Security Administration, Public Retirement Systems, RailroadRetirement Board, claims status, benefit amounts and effective dates, etc.).

TO STANDARD INSURANCE COMPANY (STANDARD INSURANCE COMPANY INCLUDES THE STANDARD BENEFITADMINISTRATORS).

l I understand that The Standard will use the information to determine my eligibility or entitlement for insurancebenefits.

l I understand and agree that this authorization shall remain in force throughout the duration of my claim forbenefits with The Standard. I understand that I have the right to revoke this authorization at any time bysending a written statement to The Standard, and that a revocation of the authorization, or the failure to signthe authorization, may impair The Standard’s ability to evaluate or process my claim. Revocation of theauthorization may be a basis for denying my claim for benefits.

l I understand that in the course of conducting its business, The Standard may disclose to other parties informationit has about me. The Standard may release this information about me to a reinsurer, a plan administrator, or anyperson performing business or legal services for The Standard in connection with my claim.

l I acknowledge that I have read the authorization and the state variations (if applicable) on the following page.A photocopy or facsimile of this authorization is as valid as the original and will be provided to me upon request.

Name (please print) Social Security No.

Signature of Claimant/Guardian/Representative Date

This Authorization is a two page document. Please see reverse page for additional terms and information. Both pages are part of the Authorization.

SI 3379 RCO 7 of 13 (7/01)

Some states require us to provide the following information to you and to those persons and entities disclosing informationabout you:

FOR RESIDENTS OF MINNESOTA

This authorization excludes the release of information about HBV (Hepatitis B Virus), HCV (Hepatitis C Virus), or HIV(Human Immunodeficiency Virus) tests which were administered (1) to a criminal offender or crime victim as a result of acrime that was reported to the police; (2) to a patient who received the services of emergency medical services personnel at ahospital or medical care facility; (3) to emergency medical personnel who were tested as a result of performing emergencymedical services. The term “emergency medical personnel” includes individuals employed to provide pre-hospital emergencyservices; licensed police officers, firefighters, paramedics, emergency medical technicians, licensed nurses, rescue squadpersonnel, or to other individuals who serve as volunteers of an ambulance service who provide emergency medical services;crime lab personnel, correctional guards, including security guards, at the Minnesota security hospital, who experience asignificant exposure to an inmate who is transported to a facility for emergency medical care; and other persons who renderemergency care or assistance at that scene of an emergency, or while an injured person is being transported to receive medicalcare and who would qualify for immunity under the good samaritan law.

FOR RESIDENTS OF NEW MEXICO

Confidential Abuse Information means information about acts of domestic abuse or abuse status, the work or home address ortelephone number of a victim of domestic abuse or the status of an applicant or insured as a family member, employer orassociate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close personal,family or abuse-related counseling relationship. For additional information about the treatment of confidential abuseinformation, see accompanying Notice of Confidential Abuse Information Practices. With respect to confidential abuseinformation, I may revoke this authorization in writing, effective ten days after receipt by The Standard, and I understand thatdoing so may result in a claim being denied or may adversely affect a pending insurance action.

Long Term Disability BenefitsAuthorization to Obtain InformationThe Standard Benefit AdministratorsPO Box 5031 White Plains NY 10602-5031 800.426.4332 Tel 800.378.8361 Fax

SI 3379 RCO 8 of 13 (7/01)

1. INFORMATION

Primary Diagnosis: ICD Code ( )

Secondary Diagnosis: ICD Code ( )

Other diagnoses and ICD Codes related to this claim.

Symptoms.

Patient’s Height: Weight: BP BP PulseRight arm Left arm Radial

Is condition primarily related to:

a. Patient’s Employment Yes No Dominant Hand Left Rightb. Mental Disorder Yes Noc. Alcohol or Drug Condition Yes Nod. Pregnancy Yes No Expected Delivery Date

Para Gravida Actual Delivery Date

Complications: Vaginal Caesarean Section

2. HISTORY

If patient was referred to you, indicate by whom:

Has patient ever had same or similar condition? Yes No

If yes, indicate when: Describe:

Do, or have, other conditions contributed to this condition? Yes No

If Yes, please explain:

Date patient first consulted you for this condition: For any condition:

Dates of subsequent treatment:

Date of most recent visit:

If patient was hospitalized, please provide dates. Admitted: Discharged:

Admitting Diagnosis: Discharge Diagnosis:

Name of Hospital:


The patient is responsible for the completion of this form without expense to The Standard Benefit Administrators.

PART A. TO BE COMPLETED BY PATIENT

Full Name: Social Security No.:

Other Names Used:


Phone No.: ( ) Birthdate: Patient No.:

Occupation: Employer: Group Policy No.:

I returned to work: Date I expect to return to work: Date

PART B. TO BE COMPLETED BY PHYSICIAN

Long Term Disability BenefitsAttending Physician’s StatementThe Standard Benefit AdministratorsPO Box 5031 White Plains NY 10602-5031 800.426.4332 Tel 800.378.8361 Fax

DEAR DOCTOR: The purpose of this form is to help us determine whether the clinical condition of your patient is disabling. We need documentationof functional impairment. Please include laboratory data and results of special tests (X-rays, CAT scan, EKG, etc.) Please attach copies of any pertinentsurgical reports, hospital admitting history, physician discharge summaries, chart notes, and narrative reports.

The patient is responsible for the completion of this form without expense to The Standard Benefit Administrators. Forms may be returned for unanswered questions.

SI 3379 RCO 9 of 13 (7/01)

Claimant’s Name:

3. ASSESSMENT

Date you recommended patient should stop working: Why?

Describe the patient’s physical, mental and cognitive limitations and work activity limitations:

How long from today’s date will the described limitations impair the patient?

Is the patient competent to endorse checks and direct the use of the proceeds?

4. TREATMENT

Planned course of treatment (Please include expected duration, surgeries, therapy, etc.)

Medications prescribed: dosage, frequency and date of prescription(s).

List other treating or referring physicians. (Continue on separate page, if necessary.)

NAME ADDRESS1.

Phone No. City State Zip Code

2.

Phone No. City State Zip Code

What reasonable work or job site modifications could the employer make to assist the individual to return to work? Please specify:

Assessment and treatment are complicated by:Malingering

Significant emotional or behavioral disorder such as depression, anxiety, hysteria. (Circle pertinent areas.)Exaggeration, inconsistent findings, subjective complaints out of proportion to objective findings, bizarre or contradictory observations.Dependence on drugs/medication. Specify:Other (please describe):

5. PROGNOSISDescribe patient’s condition since onset of symptoms: Recovered Improved Unchanged Regressed

When do you expect a fundamental or marked change in patient’s condition? Never Condition expected to regress Condition expected to improve

State anticipated date: or, Unable to determine, follow up in: months

When do you anticipate the patient can return to work? State anticipated date: or, Unable to determine, because of:

follow up in: months

Remarks:

( )

( )

Long Term Disability BenefitsAttending Physician’s StatementThe Standard Benefit AdministratorsPO Box 5031 White Plains NY 10602-5031 800.426.4332 Tel 800.378.8361 Fax

Physician’s Signature Date

Physician’s Name (Please Print) Specialty

Address City State Zip Code

Physician’s Taxpayer ID No. Phone No. ( ) Fax No. ( )

AcknowledgementI hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief.I acknowledge that I have read the applicable fraud notice on the following page of this form.

Return to: The Standard Benefit Administrators at the address above.

SI 3379 RCO 10 of 13 (7/01)





COLORADO RESIDENTS


FLORIDA RESIDENTS








SI 3379 RCO 11 of 13 (7/01)

Long Term Disability BenefitsEmployer’s StatementThe Standard Benefit AdministratorsPO Box 5031 White Plains NY 10602-5031 800.426.4332 Tel 800.378.8361 Fax

1. EMPLOYEE

Name of Employee:


Job Title (please attach a copy of job description):

If applicable, please give job classification:

Phone No. : ( ) Date Employed: Social Security No. :

2. INFORMATION

Date employee’s coverage became effective:

Was employee given a Certificate of Insurance? Yes No Don’t know

Was employee insured under Previous LTD Carrier? Yes No Effective Date: ______________________

Employee’s Medical Insurance carrier:

Phone No. : ( ) Effective date for medical insurance:

Employee’s status on date disability commenced:Actively at Work? Yes No If no, reason: Number of hours worked per week:

Last day of work before disability commenced: Exempt or Non-Exempt Union or Non-Union

Number of hours worked this day: Date employee returned to work after disability ended

Have you considered allowing the claimant to work in another occupation, or modify or alter the job duties of the claimant’s occupation, how the job is done (i.e., work schedule),

or worksite? Yes No If yes, what alternatives were offered to the claimant?

Is disability caused or contributed to by employment? Yes No Undetermined

Has employee filed a Workers’ Compensation claim? Yes No Don’t know

Workers’ Compensation Carrier Name: Claim #: Date of Injury:


Phone No.: ( ) Person to contact:

Is employment now terminated? Yes No Reason

Is employment scheduled for termination? Yes No Date of termination

Reason:

3. SALARY AT TIME OF DISABILITY Please check only one box.

Basic Monthly Earnings Monthly rate $ Basic Weekly Earnings Weekly rate $

Basic Yearly Earnings Annual rate $ Basic Hourly Earnings Hourly rate $

Basic Contract Earnings Contract amount $ Length of contract

Commissions (Please attach list of commissions paid for the period specified in your Group Policy.)

Date of last increase: Earnings prior to increase: Effective date:

4. COMPENSATION FOR PERIOD AFTER DISABILITYType Last date through which paid or payable Amount / Rate

Sick Pay

Self-insured Short Term Disability

Salary Continuation

Wages / salary, earned after disability

Commissions, earned after disability

Vacation Pay

$ per

SI 3379 RCO 12 of 13 (7/01)

9. EMPLOYER REPRESENTATIVE COMPLETING THIS FORM

Long Term Disability BenefitsEmployer’s StatementThe Standard Benefit AdministratorsPO Box 5031 White Plains NY 10602-5031 800.426.4332 Tel 800.378.8361 Fax

5. DEDUCTIBLE INCOMEIs employee covered by or now receiving benefits Covered Receivingfrom the following? Don’t Date of Amount Effective

Yes No Yes No Know Application Weekly Monthly Date

a. Social Security

b. Workers’ Compensation

c. State Disability Insurance

d. Retirement or Pension(Employer, PERS, STRS, PERA, etc.)

Please specify:

e. Other:(e.g., unemployment or union benefits)

6. LIFE INSURANCE

Was employee covered by Group Life Insurance with The Standard Benefit Administrators on cease work date? Yes No

If yes, list policy number(s):

Date life insurance became effective:Please attach original enrollment card.

Amount of Basic life insurance $ Additional $ Supplemental $ AD&D $

Dependent’s coverage? Yes No

IMPORTANT: Please continue payment of premiums until otherwise notified.

7. TAX INFORMATION

Employer’s Federal Tax I.D. Number:

Check one: We are a private-sector employer

We are a public-sector (government entity) employer

Is this employee subject to: Social Security taxes? Yes No Medicare taxes? Yes No

Railroad Tier 1 taxes? Yes No Tier 1 Medicare taxes? Yes No

State Disability taxes? Yes No Unemployment Compensation taxes? Yes No

If subject to Social Security taxes what are the employee’s year to date Social Security wages?

Does this employee pay all or a portion of the premium for LTD insurance coverage? Yes No

*If yes, what percentage of the LTD premium does the employer pay %.

*the employee pay % with “pre-tax” funds.

*the employee pay % with funds that have been taxed.

*IMPORTANT: Remember to calculate the premium contribution percentage information according to the IRS Group Policy (three year averaging) rule.

8. ATTACHMENTS

Signature: Date:

Prepared by: Title:

Phone No.: ( ) Fax No. : ( )

AcknowledgementI hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief.I acknowledge that I have read the applicable fraud notice on the following page of this form.

Please attach copies of the following.a. Job Description c. Enrollment Form for Long Term Disability Insuranceb. Employment Application or Resume d. Income From Other Sources (Deductible Benefits) Documents

(Social Security, Workers’ Compensation, PERS, etc.)

Employer: Phone No.: Policy Number:


SI 3379 RCO 13 of 13 (7/01)





COLORADO RESIDENTS


FLORIDA RESIDENTS






